RN Case Manager

Job Title

RN Case Manager

Hours Required

40

Job Description and Hours

Under the supervision of the Duet Director of Nursing, the Registered Nurse Case Manager will reflect highest standards of nursing practice, be proactive and reactive to the people supported by Duet, and provide nursing care in a manner which promotes quality, continuity, and safety of the person. The Registered Nurse Case Manager independently implements the nursing process and administers skilled professional nursing services, care, and leadership while providing, delegating, evaluating, and coordinating comprehensive professional nursing care. This person will be responsible for assessing, planning, securing and delivery of health and habilitation supports for people, and will accept responsibility for the direction, monitoring, and delegation of activities related to the provision of medication and additional activities by medication aides. Health care will be provided following physician's orders, and nursing interventions will be documented. The Registered Nurse Case Manager will make decisions, problem-solve, take initiative, and respond to emergencies with minimal direction from supervisors. The registered nurse case manager will adhere to Duet policy and procedures, as well as applicable laws, and regulations, and standards and will also carry out the mission, core values, and quality commitment of Duet. ESSENTIAL JOB FUNCTIONS :

1. Reports to work as scheduled on a regular and reliable basis.

2. Ability to accept work assignments to all division programs and to work as an effective team member at all locations.

3. Adheres to the agency’s Core Values and mission with complete regard for the dignity and respect of each person .

4. Observe person’s Rights.

5. Maintain confidentiality of people supported.

6. Provides professional nursing care utilizing all elements of the nursing process.

7. Ability to understand and support the community-based philosophy while overseeing and ensuring the health, safety, and well-being of the people supported in their homes and/or day programs, thereby being attentive to personal choices and interests.

8. Performs the following functions related to the assessment, planning, implementation, and evaluation of people on the case management caseload.

a. Assessment - Uses physical assessment skills and the data collected from all available resources to formulate a nursing database. Analyzes and interprets data to appropriately prioritize selected nursing diagnoses and identify needs. Performs ongoing assessments/observations at desig nated intervals. Identifies and documents changes in the person's health status that will affect the unlicensed employee’s ability to meet needs. Review annually prior to annual ISP or when significant medical changes occur.

b. Planning - Develops individualized care plans based on scientific knowledge and principles. Collaborates with the person, employees, health care professionals and the ISP team to establish an individualized care plan with person-centered goals and outcomes to achieve optimal health.

c. Implementation - Delegates and monitors to unlicensed employee’s and ensures that employees implement interventions based on the established individualized plan of care. Collaborates with other health care professionals and communicates with unlicensed employees to assure that the needs of the person are being met. Utilizes therapeutic communication techniques that assist the person and employees to resolve or cope with problems appropriately within their scope of practice.

d. Evaluation - Effectively evaluates the individualized plan of care and makes changes as necessary. Evaluates the effectiveness of nursing interventions, and participates with the person, employees, health care professionals, and ISP team members in the evaluation process toward achieving person centered goals. Modifies the priorities for the person and unlicensed employee based on ability to meet needs. Differentiates, selects, and implements alternate methods of meeting the needs of the person and modifies the plan of care.

9. Ability to delegate appropriate nursing care as necessary in accordance with the plan of care and accepts the responsibility and accountability of the delegation to unlicensed employees.

10. Demonstrate leadership regarding the person’s healthcare. Demonstrate leadership and creativity in problem resolution and in proposing new ideas for the person’s care.

11. Teach employees for appropriate special care procedures, training on medical equipment, cares of the person, medication issues, retraining etc. as needed.

12. Ability to use appropriate nursing judgment, schedule and provide home and day program nursing reviews as necessary to meet the needs of the person. Nursing reviews will be documented. Update plan of care as necessary for people and review appointment records, laboratory, and diagnostic tests.

13. Ability to keep thorough and legible professional documentation of medical issues while ensuring timely and accurate completion of required documentation. The Registered Nurse Case Manager audits medical documentation and medication records.

14. Oversee the person's medical issues and alert managers and direct support staff of changes in the person’s health and/or plan of care. Act as medical liaison and consultant for agency personnel while providing technical and professional assistance related to person’s health. Delegate responsibility and provide medical training for unlicensed employees.

15. Communicate with physicians, vendors, social workers, etc. as needed to provide quality care for the person. This task may be delegated as appropriate.

16. Facilitate communication of information between hospital and employees during hospitalizations.

17. Communicate to the Supervisor any issues which may impact the person, the family, and/or services.

18. Answer administration and employee questions pertaining to the person supported.

19. When requested, performs all essential responsibilities of the registered nurse while providing direct nursing support at the Medical Support Units (MSU-S/N) and the Jerry Graesser Center.

20. During work hours accept reassignment to provide direct support at MSU-N/S, Jerry Graesser Center (JGC), as need for situations when unexpected staffing needs arise, emergency response is needed, or if additional staffing is required. Adhere to the appropriate job description when performing direct care.

21. Ability to attend hospital discharge meetings, in-services, educational programs, and essential agency training.

22. Participate in required ISP meetings on nursing caseload and covers other nursing caseloads as necessary.

23. Ability to work effectively with coworkers.

a. Communicate with coworkers both verbally and in writing.

b.Recognize and respond appropriately to nonverbal and situational cues from coworkers, such as when there is a need for physical assistance with the care of a person or verbal reinforcement.

c. Create a positive work environment in the home/day program and be a motivator and leader for employees.

d. Serve as a role model for employees in tone, morale, and professionalism in interactions with the people supported, other Duet employees, family members and friends, DHHS employees, day program personnel, medical personnel, vendors, and others.

e. Ensure that employee’s documentation and follow-through meet requirements regarding MARs, medical charting, seizure records, hospitalization records, Therap and other areas of documentation.

f. Give employees feedback on implementation of tasks in a prompt, tactful, direct, and consistent way; follow through with the Manager, Coordinator, or Director of area with any concerns.

g. Be attentive and responsive to employee concerns and refer issues to appropriate personnel in the agency as needed. Demonstrate tact, kindness, and concern toward employees.

h. Promotes harmonious relationship